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      Controversias de la ooforectomía profiláctica bilateral durante la histerectomía electiva Translated title: Profilactic bilateral ooforectomy during elective hysterectomy

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          Abstract

          El término ooforectomía profiláctica implica que los ovarios son normales al ser removidos quirúrgicamente y que se realiza por posibles beneficios futuros, tales como la prevención de cáncer de ovario o evitar reintervenciones quirúrgicas ginecológicas por patología en el anexo remanente. Sin embargo, se ha sugerido que la producción de andrógenos en los ovarios perimenopáusicos tiene un papel prominente en la calidad de vida y el bienestar sexual de la mujer. Al igual que se ha relacionado la ooforectomía bilateral con un aumento en la enfermedad cardiovascular y la mortalidad en mujeres que no usaron terapia de reemplazo hormonal. Hasta que exista evidencia inequívoca proveniente de estudios controlados, aleatorizados y adecuadamente diseñados, la ooforectomía profiláctica bilateral coincidente con una histerectomía electiva en pacientes de bajo riesgo para cáncer de ovario, debe ser considerada con gran cautela. La evidencia actual sugiere que la decisión de realizarla o no durante una histerectomía electiva, se basa más en opinión que en estudios aleatorizados bien diseñados y de peso metodológico, pudiéndose no justificar la realización de tan elevado número de ooforectomías profilácticas en la práctica clínica actual.

          Translated abstract

          The term prophylactic oophorectomy implies that the ovaries are normal at the time of their surgical removal and that it is performed for possible future benefits, such as prevention of ovarian cancer or to avoid eventual gynecological surgical interventions. However, it has been suggested that the production of androgens in the ovaries in perimenopausal women has an important rol in the quality of life and sexual well being. Bilateral oophorectomy has also been related with an increased risk of cardiovascular disease and mortality in women that did not use hormonal replacement therapy. Until more research of better methodological quality becomes available, prophylactic oophorectomy at the time of an elective hysterectomy in ovarian cancer low risk women should be approached with great caution. The poor and limited evidence suggests that the decision to perform or not a prophylactic bilateral oophorectomy at the time of an elective hysterectomy, is mostly opinion-based than evidence-based, and it does not justify the elevated number of prophylactic oophorectomies seen in current clinical practice.

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          Most cited references52

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          Survival patterns after oophorectomy in premenopausal women: a population-based cohort study.

          A statistical model of death due to ovarian cancer, breast cancer, coronary heart disease, hip fracture, and stroke has suggested that women who undergo prophylactic bilateral oophorectomy are at increased risk of death for all causes. We aimed to investigate survival patterns in a population-based sample of women who had received an oophorectomy and compare these with women who had not received an oophorectomy. From an existing cohort of all women who underwent unilateral or bilateral oophorectomy while residing in Olmsted County, MN, USA, in 1950-87, we analysed those who had received an oophorectomy for a non-cancer indication before the onset of menopause. Every member of the cohort was matched by age to a referent woman in the same population who had not undergone oophorectomy. 1293 women with unilateral oophorectomy, 1097 with bilateral oophorectomy, and 2390 referent women were eligible for the study. Women were followed up until death or the end of the study (staggered over 2001-06) by use of direct or proxy interviews, medical records in a records-linkage system, and death certificates. Overall, mortality was not increased in women who underwent bilateral oophorectomy compared with referent women. However, mortality was significantly higher in women who had received prophylactic bilateral oophorectomy before the age of 45 years than in referent women (hazard ratio 1.67 [95% CI 1.16-2.40], p=0.006). This increased mortality was seen mainly in women who had not received oestrogen up to the age of 45 years. No increased mortality was recorded in women who underwent unilateral oophorectomy in either overall or stratified analyses. Although prophylactic bilateral oophorectomy undertaken before age 45 years is associated with increased mortality, whether it is causal or merely a marker of underlying risk is uncertain.
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            Methods of hysterectomy: systematic review and meta-analysis of randomised controlled trials.

            To evaluate the most appropriate surgical method of hysterectomy (abdominal, vaginal, or laparoscopic) for women with benign disease. Systematic review and meta-analysis. Cochrane Menstrual Disorders and Subfertility Group Trials Register, Cochrane Central Register of Controlled Trials, Medline, Embase, and Biological Abstracts. Only randomised controlled trials were selected; participants had to have benign gynaecological disease; interventions had to comprise at least one hysterectomy method compared with another; and trials had to report primary outcomes (time taken to return to normal activities, intraoperative visceral injury, and major long term complications) or secondary outcomes (operating time, other immediate complications of surgery, short term complications, and duration of hospital stay). 27 trials (total of 3643 participants) were included. Return to normal activities was quicker after vaginal than after abdominal hysterectomy (weighted mean difference 9.5 (95% confidence interval 6.4 to 12.6) days) and after laparoscopic than after abdominal hysterectomy (difference 13.6 (11.8 to 15.4) days), but was not significantly different for laparoscopic versus vaginal hysterectomy (difference -1.1 (-4.2 to 2.1) days). There were more urinary tract injuries with laparoscopic than with abdominal hysterectomy (odds ratio 2.61 (95% confidence interval 1.22 to 5.60)), but no other intraoperative visceral injuries showed a significant difference between surgical approaches. Data were notably absent for many important long term patient outcome measures, where the analyses were underpowered to detect important differences, or they were simply not reported in trials. Significantly speedier return to normal activities and other improved secondary outcomes (shorter duration of hospital stay and fewer unspecified infections or febrile episodes) suggest that vaginal hysterectomy is preferable to abdominal hysterectomy where possible. Where vaginal hysterectomy is not possible, laparoscopic hysterectomy is preferable to abdominal hysterectomy, although it brings a higher chance of bladder or ureter injury.
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              Hormones, mood, sexuality, and the menopausal transition

              To determine the extent of changes in women's sexual functioning and well-being during the menopausal transition and the relationship to hormonal changes. Prospective observational study. Population-based sample assessed at home. 438 Australian-born women 45-55 of years who were still menstruating at baseline. Of these, 226 were studied for effects of hormones on sexual functioning. Short Personal Experiences Questionnaire (SPEQ) and Affectometer 2 scores and annual blood sampling. From the early to late menopausal transition, the percentage of women with SPEQ scores indicating sexual dysfunction increased from 42% to 88%. Mood scores did not change significantly. In the early menopausal transition, women with low total SPEQ scores had lower estradiol level but similar androgen levels to those with higher scores. Decreasing SPEQ scores correlated with decreasing estradiol level but not with androgen levels. Hormone levels were not related to mood scores. Female sexual functioning declines with the natural menopausal transition. This decline relates more to decreasing estradiol levels than to androgen levels.
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                Author and article information

                Contributors
                Role: ND
                Journal
                amc
                Acta Médica Costarricense
                Acta méd. costarric
                Colegio de Médicos y Cirujanos de Costa Rica (San José )
                0001-6012
                September 2008
                : 50
                : 3
                : 131-135
                Affiliations
                [1 ] Hospital de las mujeres
                Article
                S0001-60022008000300002
                12d4fed1-245b-47ab-8d49-2d9f1f3b4435

                http://creativecommons.org/licenses/by/4.0/

                History
                Product

                SciELO Costa Rica

                Self URI (journal page): http://www.scielo.sa.cr/scielo.php?script=sci_serial&pid=0001-6002&lng=en
                Categories
                Health Care Sciences & Services

                Health & Social care
                hysterectomy,hormone replacement therapy,Ovariectomía,ooforectomía profiláctica,histerectomía,terapia reemplazo hormonal,prophylactic oophorectomy,Ovariectomy

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